=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578513834
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOGARD DRUG NO. 5, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1102 S WESTERN AVE
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61605-3356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-637-4487
-----------------------------------------------------
Fax | 309-637-9141
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1102 S WESTERN AVE
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61605-3356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-637-4487
-----------------------------------------------------
Fax | 309-637-9141
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CORPORATE SECRETARY
-----------------------------------------------------
Name | MRS. ANNETTE T NIMMO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 309-637-4487
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------